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Overcoming anxiety and depression in cancer

There is an increasing recognition that psychological issues are a primary concern for cancer patients, both during and after treatment. Anxiety, depression, fear of recurrence and other psychological concerns need to be addressed to maintain quality of life.

Did you know?


Approximately half of all patients with cancer experience emotional difficulties.1


Adjustment disorder is a common psychological complication, with individuals suffering from depressed mood, anxiety, lack of life satisfaction, hopelessness and/or loss of self-esteem.2


Non-specific distress and anxiety are also very common in cancer patients. Distress is the sum of multiple psychological, social, and spiritual factors. If severe enough, it can interfere with the patient's ability to deal effectively with the illness, its symptoms and the complications of treatment.

 


Psychological issues may impact behaviors that are critical for cancer survivors.3,4 In addition, survivors who have clinical depression have a two times greater risk of death from any cause, when compared to survivors who don’t have clinical depression.5


Unfortunately, research suggests that emotional needs of cancer patients are not met as they should be. For example, a survey of bone marrow transplant survivors found that half of those who reported feeling distressed said they had not received any treatment for their emotional needs.6

The Facts:


Adjustment disorder

  • Adjustment disorder can occur when someone goes through a stressful life event, including the diagnosis of cancer.
  • It can be addressed through individual psychotherapy by teaching coping skills that focus on stressors caused by the disease. Cognitive therapy was found to be useful in reducing distress and increasing quality of life in a group of patients with melanoma.7
  • Patient support groups play an important role in coping with a cancer diagnosis and the resultant distress that many survivors experience. Support groups include tumour‐specific or mixed groups, and may be either informally structured, meet at regular face‐to‐face meetings or be run by professionals who provide expert education and training.8
  • One study of 748 participants in cancer support groups in the UK showed that the most frequent reasons for joining a support group were meeting others like themselves (63.5%), finding emotional support (13%) and gaining practical advice (8%).9

Anxiety

  • Approximately 18 to 25 percent of long-term cancer survivors report anxiety.10–14 Patients may present with a complex mixture of physical and psychological symptoms, which may be expressed as:
    • Tension
    • Restlessness
    • Jitteriness
    • Hypervigilance to symptoms and events
    • Insomnia
    • Distractibility
    • Shortness of breath
    • Emotional numbness
    • Apprehension
    • Worry
  • Management of Anxiety
    • Treatment of anxiety in patients with cancer involves a combination of psychotherapy, drug-free approaches and, in some cases, medications.
    • Although many symptoms might be viewed as normal reactions to a cancer diagnosis and treatment, symptoms that are severe enough to  interfere with quality of life or the ability to perform routine activities of daily living need further evaluation and treatment.
    • Non-pharmacological therapy
      • Non-pharmacological treatments for anxiety and distress include psychotherapy and behavioral interventions used alone or in combination.15
      • Supportive psychotherapy
        • This is a short-term, solution-oriented psychotherapy that focuses on a specific problem. It deals with both crisis-related issues as well as existential issues15 and can include both the patient and family.
      • Behavioural intervention
        • A typical behavioural intervention for anxiety includes a relaxation exercise, combining deep breathing and either passive or active muscle relaxation.
        • There is evidence that progressive muscle relaxation might have benefits for patients undergoing chemotherapy.16
        • A study comparing progressive muscle relaxation and alprazolam, a drug commonly used to treat anxiety, found that both were effective in relieving mild to moderate anxiety or distress in cancer patients.17 Relaxation techniques can be used in combination with medications for highly anxious patients.
      • Exercise
        • A program incorporating strength and aerobic exercise can help reduce anxiety, with greatest improvements seen in supervised training programs. Moderate-intensity aerobic training performed three times per week over at least a 12- week period, or a combination of aerobic plus resistance training twice weekly over a 6- to 12-week period, can significantly reduce anxiety in cancer survivors during and after treatment.18
      • Stress management training
        • Even watching a video or reading material that provides instructions on stress management techniques can be beneficial and has been recommended to relieve psychological distress during treatment.19
      • Creative Arts therapies
        • For cancer patients, creative therapies like art, dance, music, and writing, appear to offer some relief for both anxiety and depressive symptoms during treatment.20
  • Management of Insomnia
    • Insomnia can be a manifestation of anxiety in cancer patients. For this condition, cognitive-behavioral therapy (CBT) has been shown to help. CBT focuses on challenging negative or faulty thoughts and behaviours and developing healthier problem-solving skills to target difficult situations.
      • A meta-analysis of CBT that included 752 cancer survivors with insomnia21 found that CBT improved sleep efficiency and reduced the severity of insomnia.

Depression

  • Depression in cancer patients can interfere with treatment and recovery and may subsequently affect their health, wellbeing and risk of death.22 Recognition of depression and choice of the appropriate level of intervention, ranging from brief counseling and support groups to medication and psychotherapy, is an important aspect of cancer care.23
    • Medications
      • These are usually prescribed for moderate to severe levels of depression. However, when compared to placebos, antidepressants for clinical depression in cancer patients do not appear to offer significant benefit. 24
    • Psychotherapy
      • Psychotherapy interventions are used to help individuals, families and groups to improve their coping skills.
      • Both group and individual treatments are effective for reducing depressive symptoms and distress and improving quality of life.23 The benefits of psychotherapy are extensive for patients with advanced incurable cancer.25,26
    • Cognitive Behavioural Therapy (CBT)
      • CBT-based interventions help patients calm exaggerated fears by encouraging them to consider different possible outcomes for their situation. Helping the patient to focus on aspects of the disease and its treatment that they have control over and encouraging behaviour change that will keep them involved and positive could provide a better quality of life. These benefits also appear to have long-term effects, with patients reporting fewer depressive symptoms several years later.27
    • Support groups
      • Support groups are important for cancer patients and family members who are distressed.28 Hospitals and community organisations will often sponsor groups that are professionally run and/or offer self-help.
    • Exercise
      • Moderate-intensity aerobic training performed three times per week over at least a 12-week period, or a combination of aerobic plus resistance training twice weekly over a 6- to 12-week period, can significantly reduce depressive symptoms in cancer survivors during and after treatment.18 Improvements in depressive symptoms appear to be greater in supervised training programs that include aerobic exercise.
    • Spiritual Interventions
      • Patients with cancer may experience reduced depression and anxiety and greater spiritual wellbeing and quality of life from interventions focused on prayer, meditation and finding meaning and purpose.29

 

What can we do about it?


If you are currently experiencing anxiety or depression after a cancer diagnosis, don't put on a "happy face" if you don't really feel this way. Share your concerns with your cancer care team.


Connect with others who listen and can help with the practical aspects of dealing with cancer. Asking family members and loved ones for this kind of support may help reduce your distress and the distress of those who care about you.


Consult with your doctor before commencing an exercise program. As much as possible, exercise regularly for at least 150 minutes per week at moderate intensity.


Try different behavioural techniques to relieve anxiety and depression, such as deep breathing and progressive muscle relaxation.


Engage in activities you really enjoy. Creative arts and music are good examples.


Go see a clinical psychologist or counselor.


Take time for spiritual reflection and prayer.

Summary:

As more research is completed, there is an increasing recognition that psychological issues are primary concerns for cancer patients during and post-treatment. Several interventions have been shown to alleviate psychological distress, anxiety and depression.

 

References

1.        Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: Five year observational cohort study. Br Med J. 2005[AK1] ;330:702. doi:10.1136/bmj.38343.670868.D3

2.        Eisenberg MG, Glueckauf RL, Zaretsky HH. Medical aspects of disability: a handbook for the rehabilitation professional. Choice Rev Online. 1993. [AK2] doi:10.5860/choice.48-3036

3.        Zhang JM, Wang P, Yao JX, et al. Music interventions for psychological and physical outcomes in cancer: A systematic review and meta-analysis. Support Care Cancer. 2012 Dec;20(12):3043-3053. doi:10.1007/s00520-012-1606-5

4.        Katz ML, Donohue KA, Alfano CM, Day JM, Herndon JE, Paskett ED. Cancer surveillance behaviors and psychosocial factors among long - term survivors of breast cancer. Cancer. 2009[AK3] ;115:480-488. doi:10.1002/cncr.24063

5.        Mols F, Husson O, Roukema JA, van de Poll-Franse L V. Depressive symptoms are a risk factor for all-cause mortality: Results from a prospective population-based study among 3,080 cancer survivors from the PROFILES registry. J Cancer Surviv. 2013;7:484-492. doi:10.1007/s11764-013-0286-6

6.        Mosher CE, DuHamel KN, Rini CM, Li Y, Isola L, Labay L, et al. Barriers to mental health service use among hematopoietic SCT survivors. Bone Marrow Transplant. 2010 Mar; 45(3):570-579. doi:10.1038/bmt.2009.166

7.        Trask PC, Paterson AG, Griffith KA, Riba MB, Schwartz JL. Cognitive-behavioral intervention for distress in patients with melanoma: Comparison with standard medical care and impact on quality of life. Cancer. 2003[AK4] ;98:854-864. doi:10.1002/cncr.11579

8.        Gottlieb BH, Wachala ED. Cancer support groups: A critical review of empirical studies. Psycho-Oncology. 2007[AK5]  Apr;16:379-400. doi:10.1002/pon.1078

9.        Stevinson C, Lydon A, Amir Z. Cancer support group participation in the United Kingdom: A national survey. Support Care Cancer. 2011;19:675-683. doi:10.1007/s00520-010-0887-9

10.      Mitchell AJ, Ferguson DW, Gill J, Paul J, Symonds P. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: A systematic review and meta-analysis. Lancet Oncol. 2013 Jul;14(8):721-732. doi:10.1016/S1470-2045(13)70244-4

11.      Boyes AW, Girgis A, D’Este C, Zucca AC. Flourishing or floundering? Prevalence and correlates of anxiety and depression among a population-based sample of adult cancer survivors 6 months after diagnosis. J Affect Disord. 2011 Dec;135(1-3):184-192. doi:10.1016/j.jad.2011.07.016

12.      Jarrett N, Scott I, Addington-Hall J, Amir Z, Brearley S, Hodges L, et al. Informing future research priorities into the psychological and social problems faced by cancer survivors: A rapid review and synthesis of the literature. Eur J Oncol Nurs. 2013 Oct;17(5):510-520. doi:10.1016/j.ejon.2013.03.003

13.      Boyes AW, Girgis A, D’Este CA, Zucca AC, Lecathelinais C, Carey ML. Prevalence and predictors of the short-term trajectory of anxiety and depression in the first year after a cancer diagnosis: A population-based longitudinal study. J Clin Oncol. 2013 Jul;31(21):2724-2729. doi:10.1200/JCO.2012.44.7540

14.      Suzuki M, Deno M, Myers M, Asakage T, Takahashi K, Saito K, et al. Anxiety and depression in patients after surgery for head and neck cancer in Japan. Palliat Support Care. 2016 Jun;14(3):269-277. doi:10.1017/S1478951515000930

15.      Watson M, Kissane DW. Handbook of Psychotherapy in Cancer Care. John Wiley & Sons; 2011. doi:10.1002/9780470975176

16.      Pelekasis P, Matsouka I, Koumarianou A. Progressive muscle relaxation as a supportive intervention for cancer patients undergoing chemotherapy: A systematic review. Palliat Support Care. 2017 Aug;15(4):465-473. doi:10.1017/S1478951516000870

17.      Holland JC, Morrow GR, Schmale A, Derogatis L, Stefanek M, Berenson S, et al. A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms. J Clin Oncol. 1991[AK6] ;9(6):1004-1011. doi:10.1200/JCO.1991.9.6.1004

18.      Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019 Nov;51(11):2375-2390. doi:10.1249/MSS.0000000000002116

19.      Jacobsen PB, Meade CD, Stein KD, Chirikos TN, Small BJ, Ruckdeschel JC. Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol. 2002[AK7]  Jun;20(12):2851-2862. doi:10.1200/JCO.2002.08.301

20.      Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013 Jun;173(11):960-969. doi:10.1001/jamainternmed.2013.836

21.      Johnson JA, Rash JA, Campbell TS, Savard J, Gehrman PR, Perlis M, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016 Jun;27:20-28. doi:10.1016/j.smrv.2015.07.001

22.      Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci. 2011;13(1):7-23.

23.      Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: A systematic review. Br J Cancer. 2006[AK8] ;94:372-390. doi:10.1038/sj.bjc.6602949

24.      Ostuzzi G, Matcham F, Dauchy S, Barbui C, Hotopf M. Antidepressants for the treatment of depression in people with cancer. Cochrane Database Syst Rev. 2018 Apr;4:CD011006. doi:10.1002/14651858.CD011006.pub3

25.      Akechi T, Okuyama T, Onishi J, Morita T, Furukawa TA. Psychotherapy for depression among incurable cancer patients. Cochrane Database Syst Rev. 2018 Nov;11:CD005537. doi:10.1002/14651858.CD005537.pub3

26.      Okuyama T, Akechi T, Mackenzie L, Furukawa TA. Psychotherapy for depression among advanced, incurable cancer patients: A systematic review and meta-analysis. Cancer Treat Rev. 2017 May;56:16-27. doi:10.1016/j.ctrv.2017.03.012

27.      Stagl JM, Bouchard LC, Lechner SC, Blomberg BB, Gudenkauf LM, Jutagir DR, et al. Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer. 2015;121:1873-1881. doi:10.1002/cncr.29076

28.      Cipolletta S, Simonato C, Faccio E. The effectiveness of psychoeducational support groups for women with breast cancer and their caregivers: A mixed methods study. Front Psychol. 2019 Feb;10:288. doi:10.3389/fpsyg.2019.00288

29.      Xing L, Guo X, Bai L, Qian J, Chen J. Are spiritual interventions beneficial to patients with cancer? a meta-analysis of randomized controlled trials following prisma. Med (United States). 2018 Aug;97(35):e11948. doi:10.1097/MD.0000000000011948

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Dr. Luiz Fernando SellaMD, MPH
Medical Doctor at the Federal University of Santa Catarina, Brazil, a Certified Lifestyle Medicine Physician and Health and Wellness Coach.